Management of local recurrence of breast cancer

This article reviews the management of isolated recurrences after primary treatment of breast cancer. These recurrences may occur within the breast after breast-conserving surgery, on the chest wall after mastectomy, or in the axilla. While often a marker of concurrent or future metastatic disease, local management with curative intent is advocated if the recurrence is isolated at presentation. Systemic therapy at this time (readjuvant) may well have benefit and should be more thoroughly investigated. Changes in breast cancer management, including sentinel lymph node biopsy, neoadjuvant chemotherapy, hormonal therapy and partial breast irradiation, may change the implications and management of isolated local breast, chest wall and axillary recurrences.     

Local control and outcome of patients irradiated for isolated chest wall recurrences of breast cancer

Between January 1970 and December 1978, 149 breast cancer patients with isolated chest wall recurrences developing after initial curative treatment (mastectomy with or without postoperative irradiation) were referred to the University Clinic for Radiotherapy and Radiobiology of Vienna. Following radiotherapy, survival was analysed in 134 patients with regard to the amount of disease in the chest wall at the time of treatment and local tumour control. Patients with "subclinical" disease (after excision of solitary recurrences) had a median survival time of 55 and 50 months for controlled and uncontrolled disease in the entire chest wall, respectively. The corresponding survival times for patients with "macroscopic" chest wall disease was 36 and 25 months, respectively. Local tumour control within the irradiated field was 69% for patients with subclinical disease and 49% for patients with macroscopic tumour manifestation. Freedom from tumours in the entire chest wall could be achieved in 41% of patients with subclinical and 24% of patients with macroscopic disease. The 5-year survival rate for patients with subclinical disease, with tumour control in the entire chest wall is 53%. Of all 134 patients, 22% survived 5 years from the time of local recurrence.     

影响乳腺癌术后局部复发因素的分析

选择主要临床与组织病理学因素和治疗因素，观察对乳腺癌术后局部复发的影响，２４２２例女性浸润性乳腺癌病人中，３年内局部复发１８２例，复发率７．５％，经过Ｌｏｇｉｓｔｉｃ回归的方法统计，年龄，绝经状态和病理类型不是影响乳腺癌术后局部复发的主要因素，而原发肿块情况，腋下淋巴结转移与否和雌激素受体状态对乳腺癌术后的局部复发的影响有意义，尤以肿块侵犯皮肤或胸壁，腋下淋巴结转移融合，雌激素受体阴性者术后复发的     

Isolated local-regional recurrence of breast cancer following mastectomy: radiotherapeutic management

Two hundred twenty-four patients with their first, isolated local-regional recurrence of breast cancer were irradiated with curative intent. Patients who had previous chest wall or regional lymphatic irradiation were not included in the study. With a median follow-up of 46 months (range 24 to 241 months), the 5- and 10-year survival for the entire group were 43% and 26%, respectively. Overall, 57% of the patients were projected to be loco-regionally controlled at 5 years. The 5-year local-regional tumor control was best for patients with isolated chest wall recurrences (63%), intermediate for nodal recurrences (45%), and poor for concomitant chest wall and nodal recurrences (27%). In patients with solitary chest wall recurrences, large field radiotherapy encompassing the entire chest wall resulted in a 5- and 10-year freedom from chest wall re-recurrence of 75% and 63% in contrast to 36% and 18% with small field irradiation (p = 0.0001). For the group with recurrences completely excised, tumor control was adequate at all doses ranging from 4500 to 7000 cGy. For the recurrences less than 3 cm, 100% were controlled at doses greater than or equal to 6000 cGy versus 76% at lower doses. No dose response could be demonstrated for the larger lesions. The supraclavicular failure rate was 16% without elective radiotherapy versus 6% with elective radiotherapy (p = 0.0489). Prophylactic irradiation of the uninvolved chest wall decreased the subsequent re-recurrence rate (17% versus 27%), but the difference is not statistically significant (p = .32). The incidence of chest wall re-recurrence was 12% with doses greater than or equal to 5000 cGy compared to 27% with no elective radiotherapy, but again was not statistically significant (p = .20). Axillary and internal mammary failures were infrequent, regardless of prophylactic treatment. Although the majority of patients with local and/or regional recurrence of breast cancer will eventually develop distant metastases and succumb to their disease, a significant percentage will live 5 years. Therefore, aggressive radiotherapy should be used to provide optimal local-regional control.(ABSTRACT TRUNCATED AT 400 WORDS)     

Successful treatment by radiation and hormone therapy of isolated local recurrence of breast cancer 24 years after mastectomy accompanied by immune thrombocytopenia: a case report

We report a case of isolated local recurrence of breast cancer, which was accompanied by idiopathic thrombocytopenic purpura (ITP) and benign monoclonal gammopathy that presented 24 years after the patient underwent mastectomy. A 72-year-old female patient with a chest wall tumor was referred to our hospital in November 1994. Twenty-four years previously she had surgically treated breast cancer, of which the pathology was scirrhous carcinoma. Needle biopsy of the tumor revealed tubular carcinoma, which is compatible with local recurrence of breast cancer. She had no evidence of regional lymph node involvement or distant metastasis. Hematological and serological examination revealed a low platelet count accompanied by M-proteinemia (IgG, kappa-type) and a mild increase in platelet-associated IgG. She was initially treated with extensive-field chest wall radiation (60 Gy), followed by systemic administration of tamoxifen. Complete local control of isolated local recurrence (LR) was achieved after radiation therapy (RT) and the patient has been progression-free for more than 2 years. Platelet count recovered gradually to a normal level after achievement of complete remission induced by radiation and tamoxifen. This may be the first case suggestive of a paraneoplastic syndrome of immune thrombocytopenia accompanied by local recurrence of breast cancer.      

Correlation between first disease-free interval from mastectomy to second disease-free interval from chest wall resection.

Between 24 November 1977 and 16 September 1988, 18 consecutive chest wall resections for recurrent breast cancer after failure of radiotherapy, were evaluated as of 1 January 1990. Chest wall involvement was the only site of recurrence in 14 patients (Group I), and the most painful of the multiple recurrences in the remaining four (Group II). Of Group I, chest wall recurrence was local in eight patients (four with necrosis after radiotherapy), regional in four, and distant in two. Chest wall reconstruction was effected by contralateral breast flap in six, by random cutaneous flap in seven and by myocutaneous flap in the remaining five. Cosmetic results were better if both marlex mesh and myocutaneous flap were used. Of Group I, at surgical/pathological staging, one recurrence with sarcomatous findings, two multiple recurrences and residual cancer in all necrosed local recurrences were found: in three of these cases radionecrosis was prominent. Mortality was 0% and surgical morbidity 5%. For Group I, median disease-free interval from mastectomy was extended from 1611 days to 3220 by recurrence resection, and disease-free interval from chest wall resection was 28% cancer-free at 1657 days, without any difference between the local vs regional-distant recurrence. Correlation factor between first and second disease interval was 0.99 and R2 was 0.98. For Group II, survival was 0% at 635 days. Chest wall resection must be considered as an important part of palliative treatment in breast cancer, but the results reflects the biology of the disease more than the chest wall surgery.     

Radiation therapy for chest wall recurrence of breast cancer after mastectomy in a favorable subgroup of patients

Purpose: Long-term outcome after radiation therapy for local–regional recurrence of breast cancer after mastectomy is generally poor. This study was performed to evaluate the long-term outcome for a potentially favorable subgroup of patients with chest wall recurrence.Methods and Materials: Of 71 patients with an isolated local–regional recurrence of breast cancer after mastectomy, 18 were identified who met the following favorable selection criteria: 1) a disease-free interval after mastectomy of 2 years or more, 2) an isolated chest wall recurrence, and 3) tumor size < 3 cm or complete excision of the recurrent disease. All 18 patients were treated with local–regional irradiation between 1967 and 1988. Radiotherapy (RT) was delivered to the chest wall to a median total dose of 60 Gy (range 30–66 Gy). Four patients received adjuvant chemotherapy and six patients received adjuvant hormonal therapy.Results: With a median follow-up of 8.4 years, nine of 18 patients were alive and free of disease. The 10-year actuarial overall and cause-specific survivals were 72% and 77%, respectively. The 10-year actuarial relapse-free survival and local control were 42% and 86%, respectively.Conclusion: Treatment for a local–regional recurrence of breast cancer after mastectomy in a favorable subgroup of patients results in a high rate of long-term survival as well as excellent local control. Aggressive treatment is warranted in this favorable subgroup of patients. 1998 Elsevier Science Inc.     

Local recurrence after mastectomy or breast-conserving surgery and radiation

Approximately 10% to 15% of patients with stage I/II invasive breast cancer will develop a clinically isolated local recurrence. The standard management of an ipsilateral breast tumor recurrence following breast-conserving surgery and radiation is salvage mastectomy, while local excision and radiation are optimal treatment of a chest wall recurrence following initial mastectomy. Although there are few data regarding the efficacy of systemic therapy after isolated local relapse, chemotherapy and/or hormonal therapy should be considered for most patients because of the high risk of subsequent distant relapse. However, local relapse does not always herald distant metastases. A prolonged interval between initial treatment and local recurrence is the most important prognostic factor for subsequent outcome, and when combined with other favorable characteristics, can predict 5-year survival rates of 70% or higher.     

Long-term results of local recurrence after breast conservation treatment for invasive breast cancer

PURPOSE: The outcome for women with a local failure after breast conservation treatment is not well described in the literature. Because local recurrence is a potentially salvageable event, this study was performed to evaluate the outcome of patients with local recurrence after breast conservation surgery and definitive radiation treatment. METHODS AND MATERIALS: The study population consisted of 112 patients with ipsilateral breast tumor recurrence. There were 100 isolated local recurrences and 12 local-plus-regional recurrences. There were 93 invasive local recurrences and 19 DCIS (ductal carcinoma in situ) local recurrences. Local recurrences were detected by physical examination alone in 42 patients, mammography alone in 47 patients, and both modalities in 23 patients. All patients were initially treated with breast conservation treatment with or without systemic therapy and subsequently treated at the time of local recurrence with salvage mastectomy with or without systemic therapy. The mean and median follow-up times after local recurrence were 49 and 44 months, respectively. RESULTS: For the entire group of 112 patients, the overall survival at 10 years after local recurrence was 69%, the cause-specific survival was 71%, and the freedom from distant metastases was 47%. For the 93 patients with an invasive local recurrence, the overall survival at 10 years was 64%, cause-specific survival was 67%, and freedom from distant metastases was 44%. For the 93 patients with an invasive local recurrence, interval from diagnosis to local recurrence (< or =2 years vs. 2.1-5 years vs. >5 years) predicted for overall survival at 5 years (65% vs. 84% vs. 89%; p = 0.03). Method of detection of local recurrence (physical examination vs. mammography vs. both methods) also predicted for 5-year overall survival (73% vs. 91% vs. 93%, respectively; p = 0.04). On multivariable analysis, interval from diagnosis to local recurrence was an independent predictor of overall survival (p = 0.03). Method of detection of local recurrence (physical examination vs. mammography vs. both methods) was borderline in predicting for 5-year cause-specific survival (73% vs. 91% vs. 93%, respectively; p = 0.06). Similarly, interval from diagnosis to local recurrence (< or =2 years vs. 2.1-5 years vs. >5 years) was a borderline predictor of 5-year cause-specific survival (65% vs. 84% vs. 89%; p = 0.08). No factors that predicted for freedom from distant metastases were identified. There were three second locoregional failures on the chest wall. Two of the 19 patients with a DCIS local recurrence have died of metastatic breast cancer. Death was probably not related to their local recurrence, but rather a result of persistent risk from an invasive primary cancer. CONCLUSIONS: This analysis provides long-term data after salvage treatment for patients who experience local recurrence after breast conservation treatment. The variables of method of detection and interval from diagnosis to local recurrence are identified as having prognostic significance for overall and cause-specific survival. In view of the potential for long-term survival, aggressive attempt at salvage treatment is warranted for the patient with local recurrence after breast conservation treatment. Second local recurrence after salvage mastectomy is an uncommon event. Although DCIS local recurrences may not in themselves cause an increase in the risk of mortality, the risk from the primary invasive cancer persists.     

The significance of local recurrence of carcinoma of the breast

One hundred twenty-one patients with local or regional recurrence of carcinoma of the breast without evidence of distant metastases were treated with megavoltage radiation therapy. All patients had radical or modified radical mastectomy as their initial treatment. The 10 year survival probability of this group of patients is 26 %, with a local control probability of 46 %. Within this group of patients with recurrent disease, factors found to be associated with a poorer prognosis include peripheral nodal recurrence, advanced initial disease stage and short disease free interval. Contrary to expectation, patients with recurrence within the mastectomy scar (as opposed to chest wall recurrence wide of the scar) or a history of previous radiotherapy had poorer local control rates (although not statistically significant), without effect upon overall survival. Comprehensive radiation therapy (peripheral lymphatic plus chest wall) enhanced the local control rate for the entire group and the survival probability for patients with isolated chest wall recurrence compared with limited radiation therapy fields. (Five year survival probability: chest wall irradiation only = 27%; chest wall and peripheral lymphatic = 54%). Patients given systemic therapy at the time of local recurrence showed no survival benefit. Aggressive, comprehensive radiation therapy is indicated for locally recurrent breast cancer. More effective systemic therapy is needed, especially for higher risk patients.     

Analysis of prognostic factors in patients with isolated chest wall recurrence of breast cancer

A retrospective analysis of a series of 162 patients treated for isolated chest wall recurrence of breast cancer after mastectomy was undertaken. Cumulative survival, distant relapse-free survival, and freedom from local progression after 5 years from the diagnosis of recurrence were 34%, 28%, and 45% respectively. Five prognostic factors influenced survival: axillary node status, primary T stage, length of disease-free interval, and number and size of recurrences. Four prognostic factors influenced the local control: axillary node status, primary T stage, disease-free interval, and number of recurrences. Patients with three or more, out of five, favorable prognostic factors fared much better than those with two or less: 75% versus 15% survival at 5 years. Our findings suggest that it is possible to identify a group of patients with a distinctly good medium-term survival and local control of disease.     

Salvage treatment for loco-regional recurrence following breast conservation therapy for early breast cancer

We reviewed the management of 55 cases of loco-regional recurrence after limited surgery and irradiation for breast cancer. Forty-three patients had disease localized to the breast, with axillary involvement in seven. Four had axillary relapse without tumor recurrence in the breast. Eight had breast recurrence extending to involve the chest wall. Mastectomy was used successfully for 41 first recurrences, and seven were controlled by wide excision; 21 of 48 patients also received chemotherapy and/or hormonal manipulation. Diffuse soft-tissue tumor required systemic therapy first, followed by wide excision when possible. Eighty-nine percent of first recurrences were controlled but disease recurred again in eight patients. Overall, 80% of cases were free of loco-regional disease at a median follow-up of 27 months. Reconstructive surgery was valuable for wound closure after wide resections, and for cosmetic procedures. Despite the previous irradiation, surgery complications were acceptable.     

电子线旋转治疗技术在乳腺癌术后胸壁照射中的应用

随着肿瘤综合治疗的不断发展,乳腺癌的治疗策略发生了很大变化。但放射治疗作为一种局部治疗方法在乳腺癌综合治疗中仍占重要地位。乳腺癌术后胸壁复发占所有局部复发的44％～69％,居第一位,成为乳腺癌术后放射治疗的最重要靶区。然而,由于胸廓特殊的几何形状,传统的照射方法难以达到合理的剂量分布。电子线旋转治疗技术利用电子线的剂量分布特点、结合胸壁的形状和靶区的深度选择不同的能量,使靶区达到合理的剂量分布,同时降低心、肺受量,在胸壁照射中具有较大的优势。临床实践也证实,电子线旋转照射与常规照射技术相比具有局部控制率高、心肺毒性小、皮肤反应轻等优点,在胸壁照射中具有较高的临床应用价值。     

Molecular markers for prognosis after isolated postmastectomy chest wall recurrence

BACKGROUND: Local chest wall recurrence after mastectomy occurs in 10-20% of patients with operable breast carcinoma. The objective of the current study was to assess the prognostic value of molecular markers at the time of local recurrence and to compare these markers with clinical variables. METHODS: Between 1975 and 1999, the authors treated 113 patients at their institution for postmastectomy chest wall recurrences with full-course external beam radiotherapy. Patients who presented primarily with lymph node recurrences or with simultaneous distant metastasis were excluded. Follow-up from the time of chest wall recurrence was 10.13 years. All clinical and pathologic data from the original diagnosis and from the time of chest wall recurrence were entered into a computerized database. Paraffin-embedded tumor specimens from the chest wall recurrences were available for 43 patients and were constructed into tissue microarrays for immunohistochemical staining of estrogen receptor, progesterone receptor (PR), p53, HER-2/neu, and cyclin D. RESULTS: Overall survival after chest wall recurrence for the entire cohort was 46% at 5 years and 28% at 10 years. The distant metastasis-free survival rate was 49% at 5 years and 40% at 10 years. Local-regional control of disease was achieved in 79% of patients at 10 years. In multivariate analysis, significant factors for distant metastasis after local recurrence were time to recurrence (< 2 years from the original diagnosis to chest wall recurrence) and PR status (distant metastasis-free survival rate: 84% [PR-positive] vs. 38% [PR-negative]; P = 0.007). The only significant factor for local-regional disease progression was HER-2/neu status. Patients with positive HER-2/neu status had a local-regional progression-free rate of 59%, compared with 92% for patients with negative HER-2/neu status. CONCLUSIONS: The prognosis for patients after local-regional recurrence of breast carcinoma is relatively poor. Longer time to local recurrence and positive PR status were associated with favorable distant metastasis-free rates and long-term survival. Positive HER-2/neu status was associated with poorer local-regional control of disease. Implications for systemic therapy and further studies are discussed.     

Survival following locoregional recurrence of breast cancer: univariate and multivariate analysis.

Although prognostic variables for locoregional recurrence of breast cancer have been evaluated by univariate analysis, multifactorial analysis has not been previously performed. In the present study, survival following chest wall and/or regional lymphatic recurrence was determined in 230 patients with locoregionally recurrent breast cancer without evidence of distant metastases treated at the Radiation Oncology Center, Mallinckrodt Institute of Radiology and affiliated hospitals. Multifactorial analysis demonstrated that the site of recurrences correlated most strongly with overall survival (p = 0.001). The 5-year actuarial overall survival was 44-49% for patients with isolated chest wall, axillary, and internal mammary lymph node recurrence. Patients with either supraclavicular, multiple lymphatic, or concomitant chest wall and lymphatic recurrence had an 21-24% 5-year overall survival. The 5-year disease-free survival was 28-37% for patients with chest wall, axillary, or internal mammary recurrences compared to 4-13% for those with supraclavicular, chest wall and lymphatic, or those with multiple sites of lymphatic recurrence. Disease-free interval from mastectomy to recurrence was also found to be a significant prognostic factor for overall survival (p = 0.005). Fifty percent of patients with a disease-free interval of at least 2 years survived 5 years following locoregional relapse, compared to 35% for those with disease-free interval of less than 2 years. In the subset of patients with small chest wall recurrences (excised or less than 3 cm) and a disease-free interval of at least 2 years, the 5-year overall and disease-free survivals were 67% and 54%, respectively. These results suggest that subsets of patients with locoregional recurrence of breast cancer can survive for long periods of time. The conventional wisdom that chest wall and/or regional nodal recurrence following mastectomy uniformly confers a dismal prognosis is not necessarily true.     

Prognosticators in recurrent breast cancer. A 15-year experience with irradiation

After initial surgery, 133 breast cancer patients, who did not receive postoperative radiation or chemotherapy, were subsequently irradiated for recurrences in the Department of Radiation Oncology, University of Maryland Hospital. All patients have been followed for a minimum of 5 years after the treatment of recurrences. An extensive analysis was done in search of prognosticators for outcome in recurrent breast cancer. Traditional prognostic factors, such as the initial axillary status, primary surgical procedure, initial menopausal status, time and site of recurrences, distant metastases and radiation dose and field issues, were investigated. No correlation was found between the initial axillary status and the overall prognosis after recurrence. The main prognosticators were: the size of the initial breast tumor, the radiation treatment for recurrences, and the presence of, or time to, distant metastases. Initial T1-T2 breast tumors were associated with a delayed onset of recurrences and a lower incidence of chest wall relapses; in turn, both the latter situations yielded the best outcome. Radiation doses of more than 4000 rad in 4 weeks delivered with locoregional fields achieved a local control rate of 72%, and the best 5-year post-recurrence survival (57%). In 52% of the recurrent breast cancer patients, distant metastases were discovered; 70% of them occurred within 2 years from recurrence. The overall post-recurrence 5-year survival for the entire series was 40%. Both the results achieved with radiation therapy and the need for a logical strategy to approach the problem of breast cancer recurrences are discussed. The situation for a large proportion of these patients is not hopeless, and many are salvagable . Combined modality approaches could offer the best possibilities of survival. However, the importance of radiation therapy in the management of these patients cannot be denied or ignored.     

Thermoradiotherapy for locally recurrent breast cancer with skin involvement.

PURPOSE: This retrospective analysis investigated the effectiveness and side-effects of combined hyperthermia and radiation therapy in locally recurrent breast cancer after primary modified radical mastectomy. The aim of the thermoradiotherapy was to reduce the substantial risk of symptomatic chest wall disease. MATERIALS AND METHODS: Between May 1995-August 1998, 39 extensively pre-treated women with progressive locoregional chest wall tumours were treated with local radiofrequency hyperthermia, given twice a week immediately before radiotherapy. Sixty-two per cent of the patients had received previous radiotherapy, with a median dose of 50 Gy, 64% had received chemotherapy, 36% hormonal therapy, and 13% local therapy with miltefosin, respectively. Nine patients were treated for microscopic residual disease after local tumour excision (R1-resection) and 30 patients for gross macroscopic nodular recurrences. Twenty-seven patients had two adjacent hyperthermia fields at the ipsilateral chest wall to cover the whole irradiation area. Each field received a median of seven local hyperthermia sessions (range 2-12, average 5.6 sessions) just before radiation therapy, with a median dose of 60 Gy (range 30-68 Gy). The monitored maximum(average) and average(average) epicutaneous temperatures were 42.1 degrees C and 41.0 degrees C, respectively. Maximum(average) and average(average) intratumoural temperatures of 43.0 degrees C and 41.1 degrees C, respectively, were achieved in nine chest wall recurrences with intratumoural temperature probes. Concurrent hormonal therapy was administered in 48%, and concurrent chemotherapy in 10% of patients. RESULTS: Median overall survival time was 28 months (Kaplan Meier), with 71% and 54% of patients living 1 and 2 years after thermoradiotherapy. The median time to local failure has not been reached, local tumour control after 2 years being 53%. Actuarial 1 and 2 year local tumour controls for microscopic residual disease were 89%, and for macroscopic nodular recurrences 71% and 46%, respectively (p = 0.09). Actuarial 1 and 2 year local tumour controls after treatment with a total dose of less than 60 Gy were 51% and 38%, respectively, and, after a total dose greater than 60 Gy, 84% and 60% (p = 0.01), respectively. Actuarial 1 year local tumour control was 92% after complete tumour remission, versus 57% after partial remission (p = 0.002). Three of the 39 patients died of cancer en cuirasse, 13 patients due to distant metastases. Acute thermoradiotherapy related erythema, dry desquamation and moist desquamation were seen in 28.2%, 30.7%, and 30.7% of patients, respectively. Soft tissue necrosis occurred in two patients with previous post-operative delayed wound healing, and in one patient above a silicon implant. CONCLUSION: This study showed that, in extensively pre-treated patients with locally recurrent breast cancer, local tumour control after thermoradiotherapy depended on tumour resectability, response of macroscopic tumour to thermoradiotherapy, and total irradiation dose.     

The results of radiation therapy for isolated local regional recurrence after mastectomy

Between 1967 and 1988 128 patients with isolated local-regional recurrence of breast cancer after mastectomy were treated with definitive radiation therapy. Recurrence was confined to a single site in 108 patients and multiple sites in 20. The chest wall was the most common location (86) and the supraclavicular region was the second most common (20). Surgical treatment for recurrence prior to irradiation consisted of excision of all gross disease in 78 patients and incisional biopsy in 49 patients. Irradiation was directed to the entire chest wall in 19% of patients with isolated chest wall recurrences and to the chest wall and regional nodes in 81%. In patients with isolated nodal failures, treatment was directed to the nodal site and chest wall in 87% and to the regional site alone in 13%. Patients with multiple sites received treatment to the chest wall and regional nodes in all cases. Electively treated sites usually received 4500-5000 cGy. Following excision of chest wall disease, the median dose was 6000 cGy. Gross disease on the chest wall received a median dose of 6100 cGy. Gross disease in nodal sites received a median dose of 5600 cGy; 66 patients received systemic therapy at recurrence. The 5-year actuarial local-regional control was 43%. In a multivariate analysis only the estrogen receptor status of the recurrence remained significant (p = .002). The 5-year actuarial survival was 49% with a relapse-free survival of 24%. In a multivariate analysis for survival, the disease-free interval (p = .007), local regional control (p = .006), and excisional biopsy for recurrence (p = .03) remained significant. In a multivariate analysis for relapse-free survival, the disease-free interval (p = .03), excisional biopsy (p = .0001), and the extent of axillary nodal involvement (p = .007) remained significant. In the subgroup of patients with a disease-free interval greater than or equal to 24 months, excisional biopsy, and local regional control, the 5-year survival was 61% with a relapse-free survival of 59%. This subgroup represents 18% of the entire group and has a relatively good prognosis after recurrence.     

Breast cancer: chest wall recurrences

Opinion statement Irradiation is indicated for patients undergoing mastectomy as surgical management for breast cancer treatment when clinical or pathologic tumor and nodal features predict risk of local/regional recurrence. Such features include: tumor size yy 5 cm, inadequate surgical margins; skin, facial, or skeletal muscle invasion; dermal lymphatic invasion; poorly differentiated tumor histology; four or more lymph nodes positive; gross extracapsular tumor nodal extension into soft tissues; and matted lymph nodes or enlarged lymph nodes > 2 cm. Patients who were treated with irradiation after mastectomy can develop local/regional recurrences despite such adjuvant therapy. General management for chest wall and nodal recurrences is structured on the extent and volume of local/ regional disease, the absence of distant metastases, the general health of the patient, and the extent of prior local/regional therapies, especially irradiation. Management of local/regional recurrence in the setting of no prior irradiation includes tumor debulking by systemic or surgical treatment followed by comprehensive chest wall and regional lymphatic irradiation. Doses are selected by tissue tolerances and volume of remaining disease. The management strategy for the patient with a history of irradiation parallels the nonirradiated patient with respect to systemic and surgical therapies to debulk the tumor to maximal response or no gross clinical disease. Radiation field design is determined by prior therapies. Doses to these fields are adjusted to normal tissue tolerance. Irradiation is given with a sensitizer such as hyperthermia or 5-fluorouracil chemotherapy. Use of radiation sensitizers can allow for a more meaningful biologic tumor effect when normal tissue tolerances prohibit delivery of standard tumor doses. Hyperthermia has been used effectively to promote complete tumor responses with use of irradiation in re-treatment cases.     

The role of postoperative radiotherapy in node negative breast cancer patients with pT3-T4 disease.

AIMS: To evaluate the role of postmastectomy radiotherapy (PMRT) in patients with pT3-T4N0M0 breast cancer. METHODS: 156 patients with T3-T4N0M0 breast cancer were retrospectively analyzed. RESULTS: Locoregional recurrences were seen in 17 of 156 patients with a median time for development of 27 months (5.7-248.7 months). Two of 9 patients who were not treated with post-operative radiation therapy had locoregional recurrence as compared with 16 of 147 patients receiving radiotherapy. In multivariate analysis, presence of locoregional recurrence was the only significant prognostic factor for overall survival (18% vs. 86%, p<0.001, RR=9.05). The patients with a median number of dissected lymph nodes >or=10 had a significantly better locoregional disease free survival rate as compared with patients with dissected lymph nodes <10 (90% vs. 78%, p=0.04). Chest wall recurrences were clearly higher in patients without chest wall RT since 5 of 49 patients without RT had recurrences in the chest wall region while only 4 of 107 who received chest wall RT had recurrence. However receiving RT to peripherical lymphatic regions had no additional effect on reducing recurrences in these regions (5% vs. 4%). CONCLUSIONS: Due to the lack of phase III randomized trials directly addressing the role of postmastectomy radiotherapy in these stages, our series suggest that postmastectomy radiotherapy to the ipsilateral chest wall is recommended for patients with PT3N0 and T4N0 breast cancer. The need for irradiating axillary or supraclavicular region shall be neglected in patients who undergo sufficient axillary sampling.